Health inspection·December 13, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on review of clinical records, facility policy, and facility documentation, and staff interviews, it was determined that the facility failed to protect the residents' right to be free from neglect by not providing all necessary emergency services for one resident requiring cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest). This failure placed 14 residents in an Immediate Jeopardy situation. (Closed Record Resident CR1 and Residents R2 through R14). Findings include: Review of the Abuse, Neglect and Exploitation policy, dated 5/19/23, stated Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy entitled Cardiopulmonary Resuscitation dated 5/19/23, revealed that if a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services and (a.) in accordance with the resident's advance directives . Review of the facility policy entitled Medical Emergency Response dated 5/19/23, revealed Policy Explanation and Compliance Guidelines: (1) The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon assistance . (3) A nurse will (a) assess the situation and determine the severity of the emergency (b) stay with the resident (c) designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. (4) a Code Blue will be announced over the intercom system, (5) all available staff will respond to the emergency accordingly, (6) The RN supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed. (7) This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS (Emergency Medical Services), (8) If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services and (a) in accordance with the residents advance directives . Review of information submitted by the facility dated 11/18/23, revealed that Nurse Aide (NA) Employee E1 found Resident CR1 unresponsive. Licensed Practical Nurse (LPN) Employee E2 began CPR with chest compressions and NA Employee E3 retrieved a backboard and ambu bag (bag to assist with breathing). Registered Nurse (RN) Employee E4 monitored the event while trying to make contact with the Page 1 of 11 396071 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some responsible party and physician. RN Employee E4 was able to get the physician on the phone and after about 30 minutes, the physician called the code (identified that the resident had ceased to breathe). During this code, it was identified that the RN [Employee E4] did not call 911. Review of Resident CR1's clinical record revealed an original admission date of 9/28/21, with a readmission date after a hospital stay of 10/24/22 with diagnoses that included diabetes, lung disease, morbid obesity, contractures, difficulty swallowing, high blood pressure, cerebral infarction (stroke) and a gastrostomy (tube placed in the stomach to provide fluids, nutrition and medications). Review of Resident CR1's Minimum Data Set (MDS- periodic review of resident care areas) dated 9/26/23, revealed the resident was not alert and oriented with a score of 00 (cognitively impaired) and needed extensive assist of two people with bed, transfer and toileting. Review of an Advance Directive (a written document of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) signed by Resident CR1's responsible party completed on 9/28/21, indicated that Resident CR1 was a full code--wanted CPR, mechanical respiration, tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water), blood or blood products, surgery or invasive diagnostic tests, kidney dialysis and antibiotics. Review of Resident CR1's most recent care plan entitled, Full Code: Family has chosen that CPR will be attempted during a cardiac arrest, dated 8/29/23, identified a care plan goal if cardiac arrest occurs, resident will receive artificial resuscitation. Full CPR will be performed by staff. Review of the physician's orders Order Summary Report dated 11/1/23, indicated that on 2/21/22, Resident CR1 was ordered as a full code. Review of clinical records as of 11/29/23 revealed that 13 residents currently in the facility were identified as full codes requiring CPR. A review of the facility investigation revealed the following: A statement obtained from NA Employee E1 on 11/14/23, at 3:32 p.m. revealed entered the room to provide care, noticed that Resident CR1 was grey and immediately got the nurse to check vitals. I remained in the room till nurse started CPR, I then left the room to continue my work and stay out of way. NA Employee E1 also indicated in the statement that the RN [Employee E4] followed into Resident CR1's room. A statement obtained from LPN Employee E2 on 11/14/23, at 11:36 a.m. revealed the LPN went into the room at 8:30 p.m. to suction Resident CR1. Resident was stable. Shortly around 9:00 p.m., a NA came out of Resident CR1's room and told the LPN Employee E2 that Resident CR1 was unresponsive. LPN assessed situation, started CPR, a NA obtained a backboard and ambu bag. Once the two staff got the backboard under the resident, CPR was restarted and continued for 25-30 minutes. The supervisor [RN Employee E4] on the shift called the family and the doctor. A statement obtained from RN Employee E4 on 11/14/23, at 10:57 a.m. revealed that at approximately 9:00 p.m. NA came out and stated that Resident CR1 was unresponsive, LPN went to room, yelled for help, NA went and grabbed the backboard and ambulance bag, and CPR was initiated. RN [Employee E4] called doctor to inform of occurrence and attempted to call family twice but unable to reach family. 396071 Page 2 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Doctor updated after 30 minutes of CPR and resident not responding no pulse or respirations, and CPR terminated. A documented conversation between the DON and the Nursing Home Administrator (NHA) with RN Employee E4, dated 11/14/23, and signed by the DON, confirmed that Resident CR1 was unresponsive, that LPN Employee E2 checked resident and called for help and began CPR, that the NA and the RN [Employee E4] obtained the backboard and ambu bag and entered Resident CR1's room and RN Employee E4 checked resident for breathing and pulse. None noted. RN [Employee E4] exited room and attempted to call family who did not answer and called physician who did not answer. CPR continued for 25-30 minutes during which time the RN [Employee E4] would go into resident room to assess for pulse and breath sounds. Doctor was notified CPR was initiated and continued for 25-30 minutes at which time the physician stopped the code. A statement obtained from NA Employee E3 on 11/14/23, at 10:59 a.m. revealed that at around 9:00 p.m. another NA Employee E1 came out of Resident CR1's room stating that Resident CR1 was unresponsive. LPN Employee E2 rushed into room, checked resident and yelled for help. NA Employee E3 grabbed the backboard, and the ambu bag. LPN was doing compressions, LPN and NA both worked on resident for 35 minutes with no response from resident. Interviews conducted by the Regional Registered Nurse on 11/17/23, revealed that LPN Employee E5, LPN Employee E6 and RN Employee E7 elicited that RN Employee E4 had stated that if Resident CR1 ever coded on his/her shift, he/she was taking a walk around the building. Additional interview conducted with the LPN Employee E2 confirmed that a code was never called and the staff working on the other end of the hall were unaware of the code, the crash cart was never brought to the code site, but the RN [Employee E4] let NA Employee E3 into the medication room to retrieve the ambu bag and backboard, The RN [Employee E4] did not assist with the code or give direction, nor did the RN [Employee E4] take notes, the LPN and NA were not relieved during the code on compressions or bagging and 911 was never called. The Clepper Manor Root Cause Analysis noted in the facility investigation revealed through a series of staff interviews, it was identified that the RN Supervisor [Employee E4] failed to announce the code to the other staff members, failed to retrieve the crash cart, failed to assist with CPR, and failed to contact 911. The report also stated that upon further interviews, staff reports the RN Supervisor [Employee E4] has commented in their presence, on numerous occasions, that should Resident CR1 code on his/her shift, he/she would take a walk around the building. During a phone interview with physician on 11/28/23, at 10:38 a.m. revealed that Resident CR1 was a full code, that the physician was sleeping when the call was received. The physician stated that the RN [Employee E4] only called once (time unsure) and that the staff was running a code, the resident had no response and code had been approximately 30 minutes. Physician stated code stopped since it was 30 minutes. During an interview on 11/28/23, at 11:14 a.m. LPN Employee E5 identified that education had been provided regarding the CPR policies, however the staff had not participated in any code drills. Additionally, LPN Employee E5 confirmed that they had heard RN Employee E4 state that if Resident CR1 had coded he/she would take a walk around the building. During an interview on 11/28/23, and 11:22 a.m. LPN Employee E6 identified that education had been 396071 Page 3 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0600 Level of Harm - Immediate jeopardy to resident health or safety provided regarding the CPR policies, however they had not participated in any code drills. Additionally, LPN Employee E5 confirmed that they had heard RN Employee E4 state if Resident CR1 had coded the RN [Employee 4] he/she would take a walk around the building. During an interview on 11/28/23, at 11:30 a.m. NA Employee E8 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. Residents Affected - Some During an interview on 11/28/23, at 11:45 a.m. RN Employee E9 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on 11/28/23, at 1:20 p.m. NA Employee E10 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on 11/28/23, at 1:20 p.m. NA Employee E11 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. The facility failed to protect the residents' right to be free from neglect by not providing appropriate standards of care to a resident with an Advance Directive of a full code, wanting all services available to sustain life by not calling 911 to provide more intense medical treatment, and the RN did not announce a code and assign designated duties to other employees working in the building, did not provide a crash cart for accessible supplies for use, did not provide guidance to the staff performing CPR and did not notify physician in a timely manner of the code situation. This failure placed 13 other full code residents at high risk for death and resulted in an Immediate Jeopardy (IJ) situation for Residents CR1, and Residents R2 through 14. On December 12, 2023, at 1:22 p.m. the Nursing Home Administrator (NHA) was notified of the IJ situation and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA on December 12, 2023, and approved at 2:41 p.m. The approved plan included: All licensed staff will be educated on Abuse/Neglect policy by 12/12/23, or educated prior to starting their next scheduled shift. All licensed staff will be educated of all necessary actions that need implemented in response t o a resident going unresponsive and honoring their code status/advance directive by 12/12/23 or educated prior to starting their next scheduled shift. This plan will be reviewed in the next QAPI scheduled for 12/13/23 and quarterly thereafter for two quarters. On 12/13/23, interviews conducted between 9:15 a.m. through 9:45 a.m. confirmed that LPN Employee E6, RN Employee E7, LPN Employee E5, NA Employee E8 and NA Employee E16 from day shift reviewed the policy on Abuse, Neglect and Exploitation and Medical Emergency Response policy. During the interviews, all staff were able to identify what abuse and neglect was, what action to take and who to report to as well as what their role was in the case of a full code medical emergency. Review of facility policies, facility documentation and education, verified that the facility had implemented the above identified action plan. 396071 Page 4 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0600 Level of Harm - Immediate jeopardy to resident health or safety The Immediate Jeopardy was removed on December 13, 2023, at 10:02 a.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management Residents Affected - Some 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 396071 Page 5 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to protect the residents' right to be free from neglect and to make certain that all emergency services were provided regarding residents requiring cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) as required by the facility. Residents Affected - Some Findings include: Review of the job description for the NHA revealed that the NHA's purpose is to direct the day to day functions of the facility in accordance with the current federal, state, and local standards, guidelines, and regulations that govern long term care facilities to assure that the highest degree of quality care can be provided to the residents at all times. Review of the job description for the DON revealed that the DON's purpose is to plan, organize, develop, control and direct the overall operation of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest level of quality care is maintained at all times. Nursing Care: assure that nursing care is provided to all residents in accordance with the Plan of Care; physician orders and resident rights are maintained. Based on the findings that the facility failed to protect the residents' right to be free from neglect and ensure that all staff implemented all emergency services interventions regarding CPR, the NHA and the DON failed to fulfill their purpose and essential job duties to ensure that the Federal and State guidelines and regulations were followed. Refer to F836 and F600 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services 396071 Page 6 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0836 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on review of clinical records, facility policy, and facility documentation, and staff interviews, it was determined that the facility failed to comply with professional standards of care in accordance with Pennsylvania Code Title 49 Professional and Vocational Standards as required for one of one residents reviewed who had requested that cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) be administered in the event that they became unresponsive with no pulse and failed to provide all necessary emergency services for one resident requiring CPR. This failure placed 14 residents in an Immediate Jeopardy situation. (Closed Record Resident CR1 and Residents R2 through R14). Findings include: The Pennsylvania Code Title 49. Professional and Vocational Standards through the Department of State indicated under the Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals. Review of the facility policy entitled Cardiopulmonary Resuscitation dated 5/19/23, revealed that if a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services and (a.) in accordance with the resident's advance directives . Review of the facility policy entitled Medical Emergency Response dated 5/19/23, revealed Policy Explanation and Compliance Guidelines: (1) The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon assistance . (3) A nurse will (a) assess the situation and determine the severity of the emergency (b) stay with the resident (c) designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. (4) a Code Blue will be announced over the intercom system, (5) all available staff will respond to the emergency accordingly, (6) The RN supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed. (7) This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS (Emergency Medical Services), (8) If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services and (a) in accordance with the residents advance directives . Review of information submitted by the facility dated 11/18/23, revealed that Nurse Aide (NA) Employee E1 found Resident CR1 unresponsive. Licensed Practical Nurse (LPN) Employee E2 began CPR with chest compressions and NA Employee E3 retrieved a backboard and ambu bag (bag to assist with breathing). Registered Nurse (RN) Employee E4 monitored the event while trying to make contact with the responsible party and physician. RN Employee E4 was able to get the physician on the phone and after about 30 minutes, the physician called the code (identified that the resident had ceased to breathe). During this code, it was identified that the RN [Employee E4] did not call 911. 396071 Page 7 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0836 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident CR1's clinical record revealed an original admission date of 9/28/21, with a readmission date after a hospital stay of 10/24/22 with diagnoses that included diabetes, lung disease, morbid obesity, contractures, difficulty swallowing, high blood pressure, cerebral infarction (stroke) and a gastrostomy (tube placed in the stomach to provide fluids, nutrition and medications). Review of Resident CR1's Minimum Data Set (MDS- periodic review of resident care areas) dated 9/26/23, revealed the resident was not alert and oriented with a score of 00 (cognitively impaired) and needed extensive assist of two people with bed, transfer and toileting. Review of an Advance Directive (a written document of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) signed by Resident CR1's responsible party completed on 9/28/21, indicated that Resident CR1 was a full code--wanted CPR, mechanical respiration, tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water), blood or blood products, surgery or invasive diagnostic tests, kidney dialysis and antibiotics. Review of Resident CR1's most recent care plan entitled, Full Code: Family has chosen that CPR will be attempted during a cardiac arrest, dated 8/29/23, identified a care plan goal if cardiac arrest occurs, resident will receive artificial resuscitation. Full CPR will be performed by staff. Review of the physician's orders Order Summary Report dated 11/1/23, indicated that on 2/21/22, Resident CR1 was ordered as a full code. Review of clinical records as of 11/29/23 revealed that 13 residents currently in the facility were identified as full codes requiring CPR. A review of the facility investigation revealed the following: A statement obtained from NA Employee E1 on 11/14/23, at 3:32 p.m. revealed entered the room to provide care, noticed that Resident CR1 was grey and immediately got the nurse to check vitals. I remained in the room till nurse started CPR, I then left the room to continue my work and stay out of way. NA Employee E1 also indicated in the statement that the RN [Employee E4] followed into Resident CR1's room. A statement obtained from LPN Employee E2 on 11/14/23, at 11:36 a.m. revealed the LPN went into the room at 8:30 p.m. to suction Resident CR1. Resident was stable. Shortly around 9:00 p.m., a NA came out of Resident CR1's room and told the LPN Employee E2 that Resident CR1 was unresponsive. LPN assessed situation, started CPR, a NA obtained a backboard and ambu bag. Once the two staff got the backboard under the resident, CPR was restarted and continued for 25-30 minutes. The supervisor [RN Employee E4] on the shift called the family and the doctor. A statement obtained from RN Employee E4 on 11/14/23, at 10:57 a.m. revealed that at approximately 9:00 p.m. NA came out and stated that Resident CR1 was unresponsive, LPN went to room, yelled for help, NA went and grabbed the backboard and ambulance bag, and CPR was initiated. RN [Employee E4] called doctor to inform of occurrence and attempted to call family twice but unable to reach family. Doctor updated after 30 minutes of CPR and resident not responding no pulse or respirations, and CPR terminated. A documented conversation between the DON and the Nursing Home Administrator (NHA) with RN Employee 396071 Page 8 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0836 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some E4, dated 11/14/23, and signed by the DON, confirmed that Resident CR1 was unresponsive, that LPN Employee E2 checked resident and called for help and began CPR, that the NA and the RN [Employee E4] obtained the backboard and ambu bag and entered Resident CR1's room and RN Employee E4 checked resident for breathing and pulse. None noted. RN [Employee E4] exited room and attempted to call family who did not answer and called physician who did not answer. CPR continued for 25-30 minutes during which time the RN [Employee E4] would go into resident room to assess for pulse and breath sounds. Doctor was notified CPR was initiated and continued for 25-30 minutes at which time the physician stopped the code. A statement obtained from NA Employee E3 on 11/14/23, at 10:59 a.m. revealed that at around 9:00 p.m. another NA Employee E1 came out of Resident CR1's room stating that Resident CR1 was unresponsive. LPN Employee E2 rushed into room, checked resident and yelled for help. NA Employee E3 grabbed the backboard, and the ambu bag. LPN was doing compressions, LPN and NA both worked on resident for 35 minutes with no response from resident. Interviews conducted by the Regional Registered Nurse on 11/17/23, revealed that LPN Employee E5, LPN Employee E6 and RN Employee E7 elicited that RN Employee E4 had stated that if Resident CR1 ever coded on his/her shift, he/she was taking a walk around the building. Additional interview conducted with the LPN Employee E2 confirmed that a code was never called and the staff working on the other end of the hall were unaware of the code, the crash cart was never brought to the code site, but the RN [Employee E4] let NA Employee E3 into the medication room to retrieve the ambu bag and backboard, The RN [Employee E4] did not assist with the code or give direction, nor did the RN [Employee E4] take notes, the LPN and NA were not relieved during the code on compressions or bagging and 911 was never called. The Clepper Manor Root Cause Analysis noted in the facility investigation revealed through a series of staff interviews, it was identified that the RN Supervisor [Employee E4] failed to announce the code to the other staff members, failed to retrieve the crash cart, failed to assist with CPR, and failed to contact 911. The report also stated that upon further interviews, staff reports the RN Supervisor [Employee E4] has commented in their presence, on numerous occasions, that should Resident CR1 code on his/her shift, he/she would take a walk around the building. During a phone interview with physician on 11/28/23, at 10:38 a.m. revealed that Resident CR1 was a full code, that the physician was sleeping when the call was received. The physician stated that the RN [Employee E4] only called once (time unsure) and that the staff was running a code, the resident had no response and code had been approximately 30 minutes. Physician stated code stopped since it was 30 minutes. During an interview on 11/28/23, at 11:14 a.m. LPN Employee E5 identified that education had been provided regarding the CPR policies, however the staff had not participated in any code drills. Additionally, LPN Employee E5 confirmed that they had heard RN Employee E4 state that if Resident CR1 had coded he/she would take a walk around the building. During an interview on 11/28/23, and 11:22 a.m. LPN Employee E6 identified that education had been provided regarding the CPR policies, however they had not participated in any code drills. Additionally, LPN Employee E5 confirmed that they had heard RN Employee E4 state if Resident CR1 had coded the RN [Employee 4] he/she would take a walk around the building. 396071 Page 9 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0836 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 11/28/23, at 11:30 a.m. NA Employee E8 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on 11/28/23, at 11:45 a.m. RN Employee E9 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on 11/28/23, at 1:20 p.m. NA Employee E10 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. During an interview on 11/28/23, at 1:20 p.m. NA Employee E11 confirmed education had been provided regarding the CPR policies, however they had not participated in any code drills. The facility failed to provide appropriate standards of care to a resident with an Advance Directive of a full code, wanting all services available to sustain life by not calling 911 to provide more intense medical treatment, and the RN did not announce a code and assign designated duties to other employees working in the building, did not provide a crash cart for accessible supplies for use, did not provide guidance to the staff performing CPR and did not notify physician in a timely manner of the code situation. This failure placed 13 other full code residents at high risk for death and resulted in an Immediate Jeopardy (IJ) situation for Residents CR1, and Residents R2 through 14. On November 28, 2023, at 2:07 p.m. the Nursing Home Administrator (NHA) was notified of the IJ situation and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA and the Director of Nursing on November 28, 2023, and approved at 4:55 p.m. The approved plan included: 1. No other residents experienced adverse effects 2. The RN Supervisor is suspended on 11/14/23 and resigned on 11/17/23 3. Immediate education on the CPR policy was started by the DON on 11/14/23. Completed on 11/22/23. 4. CPR certification cards of all involved were verified and are valid on 11/14/23. 5. Residents that are a full code were identified on 11/14/23 by the DON and she ensured the medical record has proper orders in place. 6. On 11/14/23 DON posted CPR recertification training held monthly at the Lakes of Jefferson 7. CPR certification will be monitored by the NHA/designee for compliance upon hire at least once per week for 4 weeks and annually 8. Any codes occurring in the facility will be reviewed by the QAPI to ensure appropriate standards of care are followed 9. The plan was reviewed in QAPI on 11/21/23 396071 Page 10 of 11 396071 12/13/2023 Clepper Manor 959 East State Street Sharon, PA 16146

F 0836 10. DON/designee to validate all residents have valid code status and directives Level of Harm - Immediate jeopardy to resident health or safety 11. DON/designee to validate crash cart present and fully stocked 12. All staff educated on signs and symptoms of unresponsiveness to include vitals, validating code status, and initiating CPR, obtaining crash cart and calling 911 completed on 11/22/23. Residents Affected - Some 13. Code drills five times a week to include all three shifts times two weeks On 11/29/23, interviews conducted between 1:15 p.m. through 1:45 p.m. confirmed that RN Employee E7, LPN Employees E5, E12 and E6 and NA Employee E8 from day shift had participated in one or more mock code drills and were able to identify tasks during a code. Interviews from 3:12 p.m. through 3:23 p.m confirmed second shift LPN Employee E13, RN Employee E14 and NA Employee E15 had participated in mock drills and were able to identify tasks during a code . Review of clinical records, facility policies, facility documentation and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on November 29, 2023, 3:38 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 396071 Page 11 of 11